Healthcare Provider Details

I. General information

NPI: 1023790664
Provider Name (Legal Business Name): EVGENIYA KHEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 SUMMIT AVE
OCONOMOWOC WI
53066-3844
US

IV. Provider business mailing address

1078 RIVERKNOLL CIR
OCONOMOWOC WI
53066-3478
US

V. Phone/Fax

Practice location:
  • Phone: 262-569-9400
  • Fax:
Mailing address:
  • Phone: 414-308-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14346-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number14346
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number14346
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: